Fertility-sparing surgery and fertility preservation in cervical cancer: The desire for parenthood, reproductive and obstetric outcomes

Radical trachelectomy is the ‘cornerstone’ of fertility-sparing surgery in patients with early-stage cervical cancer wishing to preserve fertility. Growing evidence has demonstrated the oncologic safety and subsequent favorable pregnancy outcomes in well-selected cases. In the absence of prospective trials, the decision on the appropriate surgical approach (vaginal, open, or minimally invasive surgery) should be based on local resources and surgeons’ preferences. Radical trachelectomy has the potential to preserve fertility in a large proportion of women with early-stage cervical cancer. However, prematurity and premature rupture of membranes are common obstetric complications after radical trachelectomy for cervical cancer. A multidisciplinary approach is crucial to optimize the balance between oncologic and obstetric outcomes. The purpose of this review is to provide an updated overview of the technical, oncologic, and obstetric aspects of radical trachelectomy.

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Fertility-sparing surgery of cervical cancer >2 cm (International Federation of Gynecology and Obstetrics 2009 stage IB1–IIA) after neoadjuvant chemotherapy

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2019-000647 ◽

2019 ◽

Vol 30 (1) ◽

pp. 115-121 ◽

Cited By ~ 4

Author(s):

Freweini Martha Tesfai ◽

Judith R Kroep ◽

Katja Gaarenstroom ◽

Cor De Kroon ◽

Rhiannon Van Loenhout ◽

...

Keyword(s):

Cervical Cancer ◽

Neoadjuvant Chemotherapy ◽

International Federation ◽

Obstetric Outcomes ◽

Clear Cell Adenocarcinoma ◽

Radical Trachelectomy ◽

Fertility Sparing Surgery ◽

Gynecology And Obstetrics ◽

Fertility Sparing ◽

Cervical Tumors

ObjectiveTo assess the feasibility, safety, oncological, and obstetric outcomes in patients with cervical tumors >2 cm treated with neoadjuvant chemotherapy in preparation for abdominal radical trachelectomy.MethodsA retrospective analysis of patients with cervical cancer >2 cm (up to 6 cm) was conducted in patients who were selected to receive neoadjuvant chemotherapy before abdominal radical trachelectomy. Surgical and clinical outcomes were examined in relation to radiological and pathological results. In addition, obstetric outcomes were described. The Mann–Whitney U test and Fisher’s exact test were performed to compare radiological findings between successful and unsuccessful abdominal radical trachelectomy procedures. International Federation of Gynecology and Obstetrics (FIGO) 2009 staging classification was used for this study.ResultsA total of 19 women were treated with neoadjuvant chemotherapy for cervical tumors >2 cm at our institution between May 2006 and July 2018. The median age was 28 years (range 19–36). The distribution of FIGO stages was seven patients stage IB1 (37%), 10 patients stage IB2 (53%), and two patients (10%) stage IIA. Mean clinical tumor size was 4.4 cm (range 3.5–6.0). Histology revealed 74% cases of squamous cell carcinoma. The remaining patients had adenocarcinoma (21%) and only one patient had clear cell adenocarcinoma (5%). Chemotherapy consisted of six weekly cycles of cisplatin (70 mg/m2) and paclitaxel (70 mg/m2). In 15 of the 19 patients (74%) fertility was successfully preserved. In the four patients in whom fertility preservation failed, one patient had stable disease after three cycles and did not meet the criteria for fertility-sparing surgery and three patients had intra- or post-operative indications for adjuvant therapy. Three of the 19 patients (15.7%) had a relapse, two of whom died. One case was in the group of successful abdominal radical trachelectomy.ConclusionNeoadjuvant chemotherapy followed by fertility-sparing surgery may be a feasible and safe option in select patients with cervical tumors >2 cm. Unfavorable prognostic factors are defined as non-responsiveness and non-squamous pathology, which can help in patient selection for fertility-sparing surgery.

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Obstetric Outcomes in Women With Early Bulky Cervical Cancer Downstaged by Neoadjuvant Chemotherapy to Allow for Fertility-Sparing Surgery: A Meta-analysis and Metaregression

International Journal of Gynecological Cancer ◽

10.1097/igc.0000000000001232 ◽

2018 ◽

Vol 28 (4) ◽

pp. 794-801 ◽

Cited By ~ 3

Author(s):

Alexandros Laios ◽

Jenneke Kasius ◽

Anastasios Tranoulis ◽

Alexandros Gryparis ◽

Thomas Ind

Keyword(s):

Cervical Cancer ◽

Neoadjuvant Chemotherapy ◽

Surgical Approach ◽

Early Stage ◽

Meta Analysis ◽

Obstetric Outcomes ◽

Live Births ◽

Fertility Sparing Surgery ◽

Fertility Sparing ◽

Meta Regression

ObjectiveIt is difficult to critically outline the optimal treatment for women with early-stage cervical cancer (eCC) wishing fertility preservation. Neoadjuvant chemotherapy (NAC) to downstage “bulky” eCC could potentially lead to fertility-sparing surgery (FSS) in a wider patient population. The rationale is to provide oncological safety balanced with maximal fertility effort. We aimed to obtain the most accurate fertility outcomes for eCC women treated with NAC followed by FSS and identify potential factors favoring fertility.MethodsA systematic search of MEDLINE, EMBASE, Web of Science, and Cochrane Database was performed. Studies that reported obstetric outcomes of eCC women treated with NAC followed by FSS were located. For the meta-analysis, we calculated the proportions of women who had the outcomes per total number of women who were considered for FSS. For the meta-regression, we extracted the relative risk of the outcome variables to enable comparison of the results across the studies.ResultsSeven studies enrolling 86 patients were included in the meta-analysis. Pooling of results from seven studies rendered summary proportions of 0.49 (95% confidence interval [CI], 0.32–0.66) and 0.42 (95% CI, 0.32–0.53) for the outcomes of pregnancies and live births, respectively. The outcome of first- and second-trimester losses by pooling seven studies rendered a summary proportion of 0.16 (95% CI, 0.09–0.27). For the outcome of premature deliveries, pooling of results from five studies rendered a summary proportion of 0.06 (95% CI, 0.02–0.16). This reached 0.29 (95% CI, 0.15–0.48) in women who achieved live births. In multivariate meta-regression, the more radical surgical approach resulted in a less favorable pregnancy rate compared with the less radical surgical approach (P = 0.015).ConclusionsThis strategy achieves live births in four of 10 eCC women who desire fertility, whereas their risk of miscarriage is low. Three of 10 live births will be premature.

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Fertility sparing surgery in early stages of cervical cancer: the new standard of care

Critical Care Obstetrics and Gynecology ◽

10.21767/2471-9803-c1-001 ◽

2018 ◽

Vol 04 ◽

Author(s):

Aleksandar Stefanovic

Keyword(s):

Cervical Cancer ◽

Standard Of Care ◽

Early Stages ◽

Fertility Sparing Surgery ◽

Fertility Sparing

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Fertility preservation in women with early ovarian cancer

Hormone Molecular Biology and Clinical Investigation ◽

10.1515/hmbci-2020-0026 ◽

2020 ◽

Vol 0 (0) ◽

Author(s):

Daniel Necula ◽

Daria Istrate ◽

Jérôme Mathis

Keyword(s):

Ovarian Cancer ◽

Fertility Preservation ◽

Low Grade ◽

Term Survival ◽

Organizational Issues ◽

Fertility Sparing Surgery ◽

Fertility Sparing ◽

Early Ovarian Cancer ◽

Reproductive Techniques

AbstractFertility preservation is an important option to consider for young women with low-grade early ovarian cancer. Fertility-sparing surgery (“FSS”) permits the conservation of the uterus and one of the ovaries. This technique is considered safe for stages IA G1, G2 and probably safe for IC G1 epithelial and non-epithelial ovarian cancers. There are still uncertainties and FSS is not fully accepted for stage IC G1, G2 and clear cell carcinoma. The difficulty in choosing the best option lies in the fact that there is a lack of prospective randomized studies, due to ethical and organizational issues. Retrospective studies and reviews showed reassuring results for FSS in terms of relapse and long term survival. The spontaneous pregnancy rate seems to decrease after FSS, but chemotherapy does not seem to have an impact on fertility rates. Compared with the general population, assisted reproductive techniques are considered safe and with similar fertility results.

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